Profile and characteristics of violence against older adults during the COVID-19 pandemic

Abstract Objective: to identify the sociodemographic profile and the characteristics of interpersonal violence against older adults during the first year of the COVID-19 pandemic in a capital city from the Brazilian Southeast region. Method: a descriptive and exploratory research study with a cross-sectional design based on the notifications of suspected or confirmed cases of violence against older adults between March 2020 and March 2021. A univariate statistical analysis and Fisher’s exact test (p<0.05) were performed. Results: a total of 2,681 notifications were recorded during the period. The main victims were individuals aged between 60 and 64 years old, female, white-skinned and with low schooling levels. The instances of violence were more frequent in the victims’ homes. Physical and psychological violence predominated, through physical force/beatings and threats, respectively. Most of the aggressors were male, younger than the victims and generally their children or intimate partners. The aggressions were perpetrated more than once and were driven by generational conflicts. There was low referral to entities for the protection of older adults. Conclusion: the sociodemographic profile found evidences vulnerable victims, subjected to many types of violence, and at a potential risk against their overall health.


Introduction
Emergence of the new coronavirus disease  in 2018 imposed the need to adopt nonpharmacological measures to prevent and control it at the global level. Social distancing stands out among the measures, leading to the need for people to stay home with their families and with as little contact as possible with other individuals, favoring more opportunities for conflicts between family members, without any possibility of resolution in a short period of time and with high chances of violence (1)(2)(3) .
Environmental factors, stress and interpersonal relationship problems were intensified, reflecting on an increase in the number of domestic violence in several countries (4) . In February 2020, China reported a three-fold increase in the number of domestic violence incidents when compared to the previous year, with the #antidomesticviolenceduringepidemic hashtag resonating and being searched more than 3 million times on the social networks. In turn, France reported an increase from 32% to 36% in the number of cases, while in North America it varied between 21% and 35% (5)(6) . The increase in the number of cases in Argentina and in the United Kingdom is estimated at 25% (6) . In April 2020, India recorded a 100% increase in the number of reports regarding this type of violence (7) . As attempts to mitigate this phenomenon, Italy and France decided to rent hotels to ensure protection of the victims, especially older adults (6) .
In Brazil, domestic violence during the COVID-19 pandemic is also a major concern. More vulnerable people, such as aged individuals, can become victims of physical, psychological and financial violence, among others types, and it is up to the health authorities and professionals to pay attention and search for dynamic and efficient coping measures to minimize or avoid such problem (8)(9) .
Violence Against Older Adults (VAOA) represents a multicausal and complex process and is considered a serious public health problem associated with the individual and collective scopes. It is defined as actions, or as absence of appropriate actions, causing harm or anguish to older adults, as a result of using physical force, of sexual, psychological or financial aggression, or of neglect or abandonment (10)(11) . In addition to these cases, institutional violence is also highlighted as a frequent manifestation in aged people living in Long-Term Institutions, which is equally difficult to identify and/or prevent.
A cohort study conducted with 897 older adults in the United States of America identified an 83.6% increase in older adults' reports of abuse, when compared to the pre-pandemic period. It was estimated that one out of ten aged individuals in the United States of America had already been a victim of violence before adopting the social distancing measures. This number rose to one out of five older adults during the pandemic (11) . A scoping review that sought to map the available scientific evidence about VAOA during the COVID-19 pandemic identified that the publications still have a low level of evidence and that the gap regarding the theme hinders developing public policies to address this phenomenon (12) . Both research studies indicated that social protection measures should be planned in epidemic and pandemic situations to welcome the victims and avoid consequences to older adults' overall health (11)(12) .
Given the above, the authors formulated the following question: Which is the sociodemographic profile and the characteristics of interpersonal violence against older adults during the COVID-19 pandemic? The hypothesis presented is that more vulnerable aged people (longerlived, black-or brown-skinned, with disabilities and living in poorer regions) have been more common victims, with frequent psychological and/or moral aggressions perpetrated by family members. It is believed that the knowledge obtained may foster planning of actions, programs to prevent and control VAOA, and public policies to protect this population segment.
The objective of this study was to identify the sociodemographic profile and the characteristics of interpersonal violence against older adults during the first year of the COVID-19 pandemic in a capital city from the Brazilian Southeast region.

Study design
A descriptive and exploratory research study with a cross-sectional approach (13) , guided by the

Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) initiative (14) .

Locus and data collection
The data were collected in the capital city of São

Study variables
The following variables of the victims were analyzed: age group, gender, race/skin color, schooling, Health Coordinating Area corresponding to the victim's residence       were indicated as probable aggressors. In relation to suspected alcohol consumption by the aggressor, no direct association was found with the types of violence.

Data treatment and analysis
The "occurrence month" variable (p=0.497) did not show a significant statistical value. The main referrals made by the professionals who assisted the victims according to the types of violence were to services from the Health Network, as shown in Table 3.
once (56.5%; n=1,517). In general, generational conflicts were found to be the drivers of the aggressions. However, the high number of "Others" and "Not applicable" answers stands out in all categories.
It is pointed out that the notification form for when there were no vaccines or treatments and whose recommendations for non-pharmacological prevention included reducing movement of people and certain level of domestic confinement (1)(2) . As a result, once lower, tensions were intensified and precipitated physical aggressions and offenses with powerful impacts on human rights and on older adults' quality of life (4) .
VAOA does not usually affect a precise age group. In fact, depending on the driver, it is more associated with conditions of frailty and dependence than with age itself.
However, a North American study mentions that the more advanced the age, the greater the aged person's difficulty notifying the event, accessing services and seeking support networks (15) . It is common that, as in this study, younger aged individuals are the ones who most frequently report the maltreatment received, although this does not necessarily mean that they are the most victimized.
In this study, it was found that age people with low schooling levels are more frequent victims of all types of violence. Such evidence is corroborated by other studies (17)(18) , indicating that it is also a reality in other countries around the world. However, a Brazilian study indicates that higher schooling levels are not necessarily a protective factor against violence (19) . In some cases, more educated people and also those with higher incomes feel embarrassed to report what happened or do not seek shelter services in situations of aggression (19)(20) . However, These regions concentrate significant points of social vulnerability in the metropolis, with high demographic density and a large population dependent on assistance benefits (22) . Such aspects significantly potentiate risk factors for violent attitudes and perpetuation of the disease (22)(23)(24) . Other relevant evidence was the fact that the aggressions have mostly occurred in the victims' homes during the pandemic and by close family members, especially children, and more than once. Therefore, Brazilian scholars point out that it is important for health professionals to be available to assist not only the victims, but also their offenders, as behaviors based solely on the victimized client may not be successful in interrupting the cycle of violence (25)(26) .
It is interesting to point out that aged people who are married or in a stable union were not free from aggressions during the COVID-19 pandemic (27) . Psychological and/ or moral violence was cited by European researchers as frequent among aged individuals (28)(29) , involving the The same is true in relation to sexual violence, where the aggressor is usually the aged person's intimate partner (27) .
However, in the case of widowhood, aged individuals experienced more financial or economic violence and situations of neglect or abandonment. Absence of a partner can cause older adults to be financially exploited by younger family members and also receive little or no assistance from them. A study carried out with mental health specialists from 23 European countries mentions that these types of violence are even more complex than the others because older adults tend to naturalize the situation when they see themselves in a position of financial providers, especially in families with very low incomes and that experience unemployment (30) . In addition to that, death of the spouse exposes the aged person to neglect on the part of family members because families had often not planned to take care of that person and are now forced to do so. It is noted that, in this study, neglect and/or abandonment were also more frequent in aged people with mental disorders, showing that such diseases can trigger rejection behaviors in older adults, leading to negligence.
The confinement imposed during the COVID-19 pandemic exposed aged people to intense family life. This aspect can be one of the factors causing family stress and physical violence impulses in younger people, as found in this study. Therefore, generational conflicts were the main drivers for aggression against older adults. These conflicts are often caused by persistent differences in social, cultural and even economic values between people belonging to different age groups (21,(28)(29)(30) .
As in other studies (19,27) , it was men that most perpetrated physical aggressions, mainly using physical force and/or beatings against the victims. It is noted that aggressors belonging to the age group from 25 to 59 years old have more muscle strength than aged people, potentially increasing the risk of serious bodily injury and even the chances of sequelae or complications. Physical injuries to older adults lead to potential complications to organs and tissues, increase the chances of systemic complications and can also lead to psychosocial harms associated with fear, shame and anger awakened by the aggressions (19) . In addition to that, relevant information obtained in the data analysis is that alcohol consumption was not mostly associated with the aggressions, a fact that differs from studies with other populations (19)(20)(21)(22)(23) .
Finally, during the service, the notifying professionals referred the older adults to services that are part of the  (32) .

Conclusion
The study identified the following as the